Electrolytes

Question 1

Normal Plasma Potassium Levels?

Answer 1

3.5-5.1 mEq/L

Question 2

Hypokalemia is Potassium below what value?
Categorize Mild, Moderate and Severe

Answer 2

1. <3.5
2. Mild = 3.1-3.5
3. Moderate = 2.5-3
4. Severe = <2.5

Question 3

What can cause hypokalemia? (4)

Answer 3

1. Decr intake (rare)
2. Incr potassium loss (kidney, GI, sweat, V/D)
3. Hypomagnesemia -> renal K wasting and decr of intracellular K
4. Drug induced

Question 4

Name some drugs that can cause Hypokalemia

Answer 4

1. beta 2 agonists
2. Theophylline
3. Levothyroxine
4. Thiazide and loop diuretics
5. High dose penicillin
6. Laxatives
7. Sodium polystyrene sulfonate
8. Patiromer

Question 5

Clinical presentation of Mild vs Moderate to severe

Answer 5

Mild = usually no sx’s

Mod to severe : depends on severity and rapidity of onset
- cramping, weakness, malaise and myalgias
Cardiac : ECG changes and arryhthmias

Question 6

1. What to do about hypokalemia and hypomagnesemia together?
2. What agents preferred for asx pt’s and symptomatic pt’s w/severe depletion?

Answer 6

tx for magnesium first! Mg is needed for K uptake

2. Oral preferred
   - IV may be necessary

Question 7

Hypokalemia : Non pharm?

Answer 7

Food : OJ, spinach, bananas, tomatoes, nuts, chocolate

Question 8

Hypokalemia : oral Potassium

1. best for?
2. Which is often used?
3. adverse effects?

Answer 8

1. asx patients
2. potassium chloride
3. Abdominal pain or cramping
   -diarrhea, nausea, flatulence
   -Hyperkalemia

Question 9

General rules
1. Admin of 10 mEq of Kcl = increase in serum K by how much?
2. Divide doses to minimize ?

3. common dosing?

Answer 9

1. 0.1 mEq/L
2. GI effects
3. 10-40 mEq daily to qid

Question 10

Hypokalemia and Iv products
1. For severe or ____ pt’s or pt’s unable to ?
2. Cons? (3)
3. MUST BE ____ before use. USe as infusion
4. What’s used to dilute it?

5. Dosing schemes? (2)
6. Recheck K after _____

Answer 10

1. symptomatic , take oral
2. Considered high risk and high alert meds , pain at infusion site , can be fatal if admined undiluted or IV push
3. DILUTED
4. NS or 0.45% saline, avoid D5W
5. 10 meq/100 mL over 1 hr (peripheral admin ok)

20mEq/50 mL over 1 hr via central line only (recc to check ECG)

6. 30-40 meq total. At least 30-60 mins after end of last infusion.

Question 11

Hyperkalemia
1. K greater than?
2. What’s Mild, mod, and severe?
3. Caused by?

Answer 11

1. 5.1
2. 5.2-5.9 , 6-6.4, >6.5
3. Incr dietary intake. Incr endog K (tumor lysis syndrome)
   Decr renal CL , Drug induced, Low renin and aldosterone state , adrenal insufficiency, hyperglycemia

Question 12

What drugs can cause Hyperkalemia?

Answer 12

Nsaids, beta blockers, cyclosporine, diabetes, elderly
Spironolactone , ACEI’s and ARBS

Question 13

Hyperkalemia : Clinical presentation ?

Answer 13

Sx’s range from asx to severe
- heart palpitations or skipped heartbeats
-Cardiac can be life threatening

Question 14

Hyperkalemia TX for MILD cases with NO ecg change

Answer 14

1. Remove potassium from Body using any K+ Binder
2. Can use furosemide 20-40 mg IVP x 1

Question 15

Moderate TX with NO ECG CHANGE?
- Name agents and process

Answer 15

1. Shift potassium intracellularly
   - use Insulin 0.1 units/kg IVP or Albuterol nebulizer 10 mg
   -or sodium bicarb infusion 50-125 mL/hr or 50 meq IVP if pH <7.15 or HCO3 <15
2. REMOVE K FROM BODY
   -Use any potassium binder

Question 16

SEVERE Hyperkalemia tx with ECG changes?
-3 steps and agents

Answer 16

1. Stabilize myocardium
   - Calc Gluc 2g IVP x1 over 10 min
   -Calc Cl 1G IVP over 5 min central line only
2. SHift potassium intracellulary (Insulin )
3. Remove potassium (K+ binders or Furosemide)

Question 17

Calc Gluconate
1. What does it do?
2. Dose and route
3. onset and duration
4. ae’s
5. MOA

Answer 17

1. stabilize heart
2. 2g IV over 10 mins
3. 1-2 mins /10-30 mins
4. Local irritation, hypercalcemia, hypotension, bradycardia
5. INCR cardiac threshold potential and reverse ECG changes

Question 18

Regular Insulin
1. What does it do?
2. Dose and route
3. onset and duration
4. ae’s
5. MOA

Dextrose 50%
1. only given with insulin to prevent ____ if glucose < ____
2. DOse and route?
3. AE’s?

Answer 18

1. shift K intracellularly
2. 10 units IV or 0.1 units/kg
3. 30 mins / 2-6 hrs
4. hypoglycemia
5. incr K uptake into cells
6. hypoglycemia, 300
7. BG < 150 (25 g or 50 mL IV over 5 mins for 2 doses)
   -BG 150-300 : 25 g (50 mL) IV over 5 mins x 1 dose
8. Hyperglycemia

Question 19

Albuterol : Shift K

1. Dose?
2. AE’s

Sodium Bicarb : Shift K

1. For what conditions?
2. Dose and route?
3. Ae’s ?

Answer 19

1. 10-20 mg nebulized
2. tachycardia and tremor
3. pH < 7.15 or HCO3 < 15
4. 50 meq IV over 5 mins or 50-125 mL/hr infusion
5. hypernatremia , metabolic alkalosis

Question 20

Remove the K

1. Furosemide
   Dose? AE’s?
2. Sodium Polystyrene sulfonate (Kayexalate)
   Dose? AE?s Instructions?

Answer 20

1. 20-40 mg IV push x 1 dose
   - low electrolytes , metab alkalosis, dehydration
2. Oral : 15-30 grams every 4-6 hrs as needed. Rectal : 30 g in 100 mL, retain 30 mins

• N/V, diarrhea, Decr Mg, K, and Ca, Incr Na, edema and colon necrosis
  -sep from other meds by 3 hrs

Question 21

Remove the K

3. Patiromer (Veltassa) Powder
   Dose? AE’s
4. Sodium zirconium cyclosilicate (Lokelma powder)
   - Dose and AE’s ?

Answer 21

3. 8.4 mg by mouth once daily (Max is 25.2 g/day)

• GI Upset, constipation , DECR Mg and K, sep from other meds by 3 hrs and store in fridge

4. 10 g TID for up to 48 hrs; then 10 g once daily

• GI upset, DECR K, Edema, Separate from other meds by 2 hrs, store at room temp

Question 22

Which can be used for recurrent episodes or chornic hyperkalemia?

Most commonly used in pt’s with ?

Answer 22

Patiromer and sodium zirc cylclo

-CKD , HF. Can help facilitate optimal RAASi therapy

Question 23

MAGNESIUM
1. Normal?
2. Causes of HYPO?
3. Most pt’s are?
4. What general sx’s?

Answer 23

1. 1.7-2.6
2. GI like malnutrition of alcoholism, Vomiting, diarrhea. Drug induced like laxatives, aminoglycosides, amphotericin B
3. Asymptomatic
4. Neuro –> convulsions in severe
   Neuromusc –> Muscle twitching, tremor, weakness, cramping
   Cardio –> Changes in ECG , wide QRS, peaked T wave
   - if severe, prolonged pr and diminished T wave

Question 24

What’s Moderate and severe hypomag?

Answer 24

Mod : 1.2-1.6
Severe <1.2

Question 25

Hypomag tx 1. If Severe Mag with life threatening sx's? 2. If severe, but sx's are NOT life threatening?

Answer 25

1. Mag sulfate 2g IV over 2 mins (Hypotension, flush, sweat) -only used in emerg - followed by 2g IV over 20 mins -followed by 2-4g IV over 2-4 hrs then repeat serum Mg 2. Mag sulfate 8 grams IV over 8 hrs, then repeat serum Mg - If mag levels are 1.2-1.6 but umable to take oral, Mg sulfate 4 g IV over 4 hrs, repeat serum Mg

Question 26

How do you tx moderate or asymptomatic (1.2-1.6)?

Answer 26

Incr dietary mg - oral mag replacement -Usually magOX 400 mg tab 1-2 tabs BID or TID. HIghest risk of diarrhea

Question 27

HYPERmagnesemia - rare except in ? -___ disease, hypo___, DKA - Drug induced ?? (3)

Answer 27

1. Kidney disease (AKI or CKD stages 4 or 5) -renal impairment + taking mag containing antacids Addison's. thyroidism. lithium, overusing mag citrate or mag antacids -parenteral mag for preeclampsia

Question 28

HYPERmag Clinical manifestations ? TX 3 steps

Answer 28

lethargy, confusionn, dysrhythmias, muscle weakness 1. Protect myocard -1-2 g IV calc gluc to antag Mg effects 2. INCR Mg Output - lasix 20-40 mg IV with 0.45% sodium chloride if normal renal function or CKD stage 1-4 -pt's with ESRD --> dialysis 3. STOP input. Limit mag in diet or meds

Question 29

Normal Plasma Ca2+ ? Normal Ionized or free calcium thats active?

Answer 29

8.6-10.2 1.13 -1.32

Question 30

What's the corrected calcium equation? -Not recommended to use in ?

Answer 30

measured Ca (mg/dL) + 0.8 (4-albumin g/dL) -critically ill pt's

Question 31

Hypocalcemia Values? -caused by?

Answer 31

calcium < 8.6 mg/dL; ionized Ca <1.1 mMol/L Alteration in PTH or VITD -Vit D deficiency (most common) -Hypomag(Impairs PTH activity)

Question 32

IV calcium products : describe 2 and elemental Ca per each product

Answer 32

1. Calc chloride -elemental Ca = 27.3% -vein irritation! tissue necrosis! -best with central line! -Max rate 1 g over 10 mins 2. Calc gluc - elemental = 9.3% Less vein irritation Max rate = 3g IV over 10 mins

Question 33

Oral calcium products? (2) -elemental ca?

Answer 33

1. Calc acetate - 169 mg per 667 tab 2. Calc carb

Question 34

Hypercalcemia Values ? Mild-mod severe Causes ? meds ? Sx's? Name 1 tx

Answer 34

>10.2 Mild/mod : 10.3-13 Severe > 13 -TZD diuretics, VitD, Lithium, calc, theophylline, tamoxifen, ganciclovir -Fatigue, weakness, anorexia, cog dysfunction, Polyuria, polydipsia, nocturia -Normal Saline. 1-2 L bolus followed by 200-300 mL/hr until fluid resuscitated

Question 35

Phosphorous Normal? Hypophos can be due to ? Hypophos acute sx's? Severe?

Answer 35

2.5-4.5 Impaired intest abs. Diarrhea, alcoholism, diet, binders such as alum and mag antacids -increased renal elim thru VitD deficiency, hyperparathyroidism, hyperglycemia induced osmotic diuresis -drugs like diuretics, glucocorticoids (dex, pred), sodium bicarb ACUTE : organ dysfunction, seizure, coma SEVERE : Muscle weakness, confusion, seizures, coma

Question 36

IV PHOS -For what condition? -Products? -How much phos in each ? -How does each product differ?

Answer 36

1. Severe< 1.5 mg/dL or unable to take oral 2. Sodium phos, potass phos 3. 3 mmol/mL 4. Sodium Phos has 4 mEq Na+/mL Potass Phos has 4.4 mEq K+/mL

Question 37

For asympt mild-mod do u need tx? For mild to mod with evidence of deficit what's the tx?

Answer 37

usually no Oral phos

Question 38

What oral phos products are available and describe how much phos, potassium, and sodium are in them ?

Answer 38

1. K-phos, neutral - 8 mmol of phos, 1.1 mEQ of Potass, 13 mEq of Sodium 2. Neutra phos K -8mmol of phos, 14.3 mEq of potassium